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Findings

A written finding is a formal document handed down by a coroner following an investigation into a death or fire and is generally the final step in the coronial investigation process. A written finding is made regardless of whether an inquest is held or not.

A written finding following an investigation into a death will usually, if possible, include:

  • the identity of the person who died
  • the time, date, and location where the death occurred
  • a summary of the evidence relating to the circumstances of the death, in some cases
  • comments or recommendations made by the coroner aimed at preventing similar deaths, in some cases.

Findings are published when:

  • an inquest was held
  • recommendations have been made
  • a coroner otherwise orders they be published.

Findings handed down and published are available below.

Search older findings on the Australasian Legal Information Institute database (AustLII).

Please consider that it may be upsetting to read details about a death or fire in an inquest finding. Some information may be graphic or distressing.

Use the search field above to locate a finding. You can search for a name, a case number, type of death or location of death.

Any person may apply for some or all of a finding to be reviewed and/or appealed.

    Recommendations

    The Coroners Act 2008 allows a coroner to make recommendations as part of their finding following an investigation into a death or fire.

    Recommendations can be made to any Minister, public statutory authority or entity that may help prevent similar deaths. A public statutory authority or entity who receives a recommendation from a coroner must respond, in writing, within three months stating what action, if any, has or will be taken.

    The Court will publish inquest findings with recommendations and the subsequent responses below.

    Findings list

    Name Case ID Case type Sort descending Date Coroner Related orders and rulings Responses to recommendations
    Gethin Roberts COR 2004 1420 Finding into death with inquest 06/05/2005 Coroner Phillip Byrne
    Joanne Elizabeth Howell COR 2007 1498 Finding into death with inquest 26/08/2011 Deputy State Coroner Paresa Spanos
    Preetika Sharma COR 2012 1543 Finding into death with inquest 08/05/2015 State Coroner Judge Ian L Gray
    Helen Maree Stagoll COR 2010 1624 Finding into death with inquest 29/10/2013 Coroner Jacinta Heffey
    Wladislaw Kowalzcyk COR 2010 1763 Finding into death with inquest 27/07/2011 Coroner John Olle
    Joeanne Maree Brady COR 2007 1816 Finding into death with inquest 14/01/2010 Coroner John Olle
    Glenn Albert Sanders COR 2014 1884 Finding into death with inquest 24/10/2017 Coroner John Olle
    Edward Tappe COR 2013 1953 Finding into death with inquest 20/05/2014 Coroner Audrey Jamieson
    Caterina Montalto COR 2011 2017 Finding into death with inquest 18/12/2013 Coroner Heather Spooner
    Elizabeth Anne Palmer COR 2016 2133 Finding into death with inquest 19/03/2018 Coroner Phillip Byrne